St. Michael School Medication Form printable pdf download

St. Michael School Medication Form

ST. MICHAEL SCHOOL

MEDICATION FORM

2016-2017

STUDENT’S NAME: _______________________________ GRADE _______

I hereby authorize the staff of St. Michael School to administer the following medication in the following dosage to my

child. I release St. Michael from all liability for administering the stated medication in the stated dosage.

MEDICATION ________________________________________________________

Condition for which prescribed ___________________________________________

Possible side effects ___________________________________________________

Instructions for usage __________________________________________________

Dosage ________________________ Times ______________________________

Date(s) _____________________________________________________________

Physician signature __________________________________________________

Address _______________________________ Phone _________________

Parent/Guardian Signature ____________________________________________

Work Phone ___________________________ Cellular _________________

Home Phone __________________________ Other ___________________

Note: This form is REQUIRED by the Archdiocese in the administering of any and all medication to students.

ALL PRESCRIPTION MEDICINE must be in its original container, with prescription label attached (this is the physician’s

written authorization), parent signature and accompanied with this form.

ALL OVER THE COUNTER MEDICINE (including Tylenol, Advil, Cough Drops, Calamine Lotion, Benadryl, etc.) MUST HAVE

A PHYSICIAN’S SIGNATURE, be in its original container, and have on this form a parent signature.

St. Michael School Medication Form